by Shannon Langston
Department of Emergency Medicine
Vanderbilt Medical Center
She was only six years old. She had somehow fallen from a height, landing on her head…unfortunately on concrete. It’s always concrete here. Her father told me she had been knocked unconscious immediately and she had not spoken since she fell. She had not vomited, but she also had not moved since the fall.
My residents and I performed a physical exam on the girl based on the “ABCDE” pneumonic I had been reinforcing: Airway, Breathing, Circulation, Disability, and Exposure. It is designed to simplify the assessment of trauma victims and to ensure that examinations are performed that same, every time, by every person. The theory is that if you do something the same way every time, there is less of a chance that you will miss something important.
Her airway was intact and she was breathing, and her blood pressure was just slightly elevated. Unfortunately, she was still unconscious and I could not get her to respond with movement, even to painful stimulation. A careful head to toe examination revealed only a large lump on the back of her head. Her pupils were slowly reactive and equal, but she stared blankly, not bothering to blink or look away as I shined the light in her eyes. The residents started IV’s and prepared airway equipment should it become necessary, riding with her across the street to the CT scanner, a relatively new diagnostic modality in Guyana.
The images showed an epidural hematoma. Essentially, it is a big blood clot pressing against her brain. It was dangerously close to damaging structures essential for life. Luckily, her spine was not injured in the fall. Although there is no formally trained neurosurgeon at Georgetown Public Hospital, a general surgeon has taken on the task. Mentored by a Canadian Neurosurgeon that works in Guyana for a few weeks a year, he has learned the basics of brain surgery. When he has questions, he will send photos of the patient, and CT scan, over his cellular phone to the neurosurgeon for guidance. He has had great success, although he often wishes for others to bounce his ideas off of or someone to help him refine his technique in shunt placement.
This small girl had a serious injury, and none of us were sure she would have a good outcome. The surgeon took her immediately to the operating room and relieved the pressure growing inside her head. He placed a small drain for the blood to evacuate and transferred her to the pediatrics ward, a large open room with multiple beds and cribs. Within several hours she opened her eyes and started to moan.
I checked on her for the next three days hoping to see her up and smiling, perhaps talking. Her family stayed at her bedside, hoping along with me. Unfortunately she would only lie there, sometimes moaning in discomfort, other times appearing to sleep. The fourth day I went in and noticed she was missing. I feared the worst. The nurses informed me that she had been discharged. She had been talking and playful since the day before and the drain had been removed from her head. I was fortunate enough that my student had taken the time to get a photograph of her prior to her discharge. It shows her standing in her bed (with rails up), smiling at the camera.
That a general surgeon would take it upon himself to be the neurosurgeon for those in need, without a formal residency, is a demonstration of the kindness and ingenuity of the Guyanese.